HART AND SCHWARTZ 467

9. Hemmig SB, Johnson RS, Farraro N: Management of a ruptured pseudoaneurysm of the sphenopalatine artery following a Le Fort I osteotomy. J Oral Maxillofac Surg 45:533, 1987

10. Newhouse RF, Schow SR, Kraut RA, et al: Life threatening haemorrhage after Le Fort I osteotomy. J Oral Maxillofac Surg 40:117, 1982

I I. Welman K: On Le Fort I osteotomy. Scand J Plast Reconstr Surg [Suppl] 12:19, 1974

12. Brady S, Courtemandre A, Steinbok P: Carotid artery thrombo- sis after elective mandibular and maxillary osteotomies. Ann Plast Surg 6:121, 1981

13. Lanigan DT, Romanchuk K, Olson CK: Ophthalmic complica- tions associated with orthognathie surgery. J Oral Maxillofac Surg 51:480, 1993

14. Uttley D, Moore A, Archer D J: Surgical management of midline skull-base tumor: A new approach. J Neurosurg 71:705, 1989

J Oral Maxillofac Surg 53:467-469, 1995

Cavernous Hemangioma of the Masseter Muscle:

Report of a Case

BRIAN HART, DDS,* AND HARRY C. SCHWARTZ, DMD, MD1-

Intramuscular hemangiomas are relatively rare, ac-

counting for less than 1% of all hemangiomasJ Of

these, 14% occur in the head and neck. The masseter

and trapezius muscles are the most common sites of involvement. 2-5 Because of their infrequency, deep lo-

cation, and unfamil iar presentation, these lesions are seldom correctly diagnosed clinically. The following

report describes a case that clinically resembled unilat- eral benign masseteric hypertrophy.

Report of Case

A 9-year-old Hispanic girl was referred to our service by Pediatric Surgery in June 1983 with a complaint of a painless swelling of the left cheek causing facial asymmetry. Her parents had first noticed the swelling when she was 2 years of age.

Examination showed a fullness in the left buccal region below the zygomatic arch (Fig 1A). The area was nonpulsi- tile and there were no bruits present on auscultation. When the patient clenched her teeth, a firm bulge appeared along the superior aspect of the masseter muscle just inferior to the zygomatic arch (Fig 1B). This association with contrac- tion of the masseter muscle led to a clinical diagnosis of unilateral benign masseteric hypertrophy. The patient's par- ents were concerned about the cosmetic deformity caused by this lesion and at their request, she was electively admit-

* Attending Surgeon, Harbor-UCLA Medical Center, Torrance, CA, and in private practice, Los Angeles and Bellflower, CA.

t Chief, Maxillofacial Surgery, Southern California Permanente Medical Group; Associate Professor, University of California, Los Angeles, CA.

Address correspondence and reprint requests to Dr Schwartz: 4900 Sunset Blvd, Los Angeles, CA 90027.

© 1995 American Association of Oral and Maxillofacial Surgeons

0278-2391/95/5304-001953.00/0

ted for surgical exploration and probable partial resection of the left masseter muscle. Admission laboratory examination included a complete blood count, coagulation screen, and urinalysis that were within normal limits.

Under general anesthesia using endotracheal intubation, an incision was made in the left retromandibular area from the tragus of the ear to approximately the antegonial notch. The dissection was carried anteriorly and superiorly just su- perficial to the masseter muscle. As in many children, the parotid gland was not well developed. The branches of the facial nerve were clearly identified in the surgical field. The dissection was continued to the area where most of the swell- ing was noted on clinical examination. At this point, near the origin of the masseter muscle on the zygomatic arch, a vascular lesion was noted to be protruding in an aneurysmal fashion between the muscle fibers (Fig 2). Compression of the inferior portion of the masseter caused a ballooning ef- fect, which corresponded to the area of tumescence observed clinically. It was evident that this was a true vascular lesion located within the substance of the masseter muscle rather than masseteric hypertrophy. By careful blunt dissection of the muscular fibers, it was found that much of the lesion, aside from the obvious aneurysmal dilatation, arose from beneath the anterosuperior aspect of the muscle. It was be- lieved that the remainder of the lesion would not be surgi- cally accessible without risking serious hemorrhage. There- fore, the aneurysmal portion was cross-clamped, excised, and sent for histologic examination. The lumen of the lesion was oversewn with vascular sutures. Closure of the wound was accomplished without difficulty.

The patient had an uneventful postoperative course. On the second postoperative day, angiograms were performed on the left internal and external carotid arteries and no abnor- mality was noted. This suggested a low-flow lesion with slow filling. Magnetic resonance imaging (MRI) was not available at that time. The histologic appearance was consis- tent with a diagnosis of cavernous hemangioma (Fig 3).

The patient was offered additional treatment in the form of sclerotherapy or embolization, but her parents were con- cerned with potential risks and opted against doing anything further. An MRI was carried out in 1987. It showed a mass

4613 CAVERNOUS HEMANGIOMA OF THE MASSETER MUSCLE

FIGURE 1. A 9-year-old Hispanic girl referred for evaluation of a swelling in the area of the left masseter muscle. A, Patient with mandible at rest. B, A firm bulge appears beneath the zygomatic arch at the anterior aspect of the masseter muscle when the patient clenched her teeth.

of uniformly high signal intensity within the left masseter muscle, consistent with an intramuscular hemangioma. She has now been followed for 11 years and there has been little change clinically. She continues to decline further treatment.

Discussion

The diagnosis of intramuscular hemangioma can be difficult. With the rarity of these lesions, their deep

location, and their variable clinical presentation, previ- ous investigators acknowledge that the preoperative diagnosis is rarely accurate. 4'6

Although intramuscular hemangiomas, in general, show an equal sex distribution, involvement of the masseter muscle has a definite male predominance (3:1). Approximately 90% of these lesions develop be- fore the age of 30 years. 2 Pain is the most common symptom, present in about 60% of all patients. Thrills, bruits, and pulsations are uncommon findings and usu- ally indicate large vessel involvement. Occasionally, maneuvers that increase venous pressure or contract

FIGURE 2. A lesion that resembles a large dilated vein protrudes along the anterior edge of the masseter muscle.

FIGURE 3. Photomicrograph showing multiple vascular lumens lined by endothelial cells, consistent with cavernous hemangioma (hematoxylin-eosin stain, original magnification ×440).

LUTCAVAGE, SCHABERG, AND FULBRIGHT 469

the musculature may disclose the lesion cl inical ly. 6 Because of their location, masseter ic lesions have been commonly mis taken for parot id masses. 3

This case c l in ical ly resembled benign masseter ic hy- per t rophy (BMH). B M H is an uncommon lesion that must be included in the differential d iagnosis of masses found in the cheek. Al though the average age of pa- tients with B M H is 30 years, occasional cases have been repor ted in ch i l d r en ] For ty percent are unilateral in nature. Clenching the teeth usual ly converts these swell ings into firm masses at tached to the under lying mandible . Often flaring or " s p u r s " are seen at the angle of the mandib le in posteroanter ior radiographs. 7'8

In general , once parot id pa thology or an infectious process has been ruled out, BMH, a neoplasm, or a vascular lesion must be suspected in all swel l ings o f the cheek. Al though Finn et al 9 rev iewed 375 vascular lesions and found that 96% could be d iagnosed by

history and cl inical examinat ion alone, intramuscular lesions remain elusive. Contras t -enhanced computed tomography or M R I are excel lent diagnost ic modal i t ies in such situations. They enable the cl inician to differen- tiate between neoplast ic and vascular processes and have been ci ted as being ex t remely effect ive in estab- l ishing the diagnosis of benign masseter ic hyper t ro- p h y ] Al though angiography is useful in the diagnosis

of vascular formations, l° it may not be helpful for im- aging lesions that do not contain large vessel connec- tions. 2

References

1. Watson WL, McCarthy WD: Blood and lymph vessel tumors: Report of 1056 cases. Surg Gynecol Obstet 71:569, 1940

2. Welsh D, Hengerer AS: The diagnosis and treatment of intra- muscular hemangiomas of the masseter muscle. Am J Otola- ryngol 1:186, 1980

3. Stofman GM, Reiter D, Feldman MD: Invasive intramuscular hemangioma of the head and neck. Ear Nose Throat J 68:612, 1988

4. Wolf GT, Daniel F, Krause C J, et al: Intramuscular hemangioma of the head and neck. Laryngoscope 95:210, 1985

5. Broniatowski M: Intramuscular hemangioma of the masseter and sternocleidomastoid muscles. Ear Nose Throat J 72:303, 1993

6. Conley JJ, Clairmont AA: Intramuscular hemangioma of the masseter muscle. Plast Reconstr Surg 54:121, 1977

7. Iizuka T: Excessive transverse facial width: Surgical correction of masseteric muscle hypertrophy, in Bell WH (ed): Modem Practice in Orthognathic and Reconstructive Surgery. Phila- delphia, PA, Saunders, 1992, pp 426-439

8. Riefkohl R, Georgiade G, Georgiade NG: Masseter muscle hy- pertrophy. Ann Plast Surg 12:528, 1984

9. Finn MC, Glowacki J, Mulliken JB, et al: Congenital vascular lesions: Clinical application of a new classification. J Pediatr Surg 18:894, 1983

t0. Yeoman CM: Management of hemangioma involving facial, mandibular, and pharyngeal structures. Br J Oral Maxillofac Surg 25:195, 1987

J Oral Maxillofac Surg 53:469-4"73, 1995

Sphenoid Carcinoma: Report of a Case

GREGORY J. LUTCAVAGE, DDS,* SIEGFRIED J. SCHABERG, DDS, PHD,* AND DEBORAH K. FULBRIGHT, MD1-

Carc inoma of the paranasal sinuses accounts for 0.2% of all neoplasms.1 Pr imary carc inoma of the sphe- noid sinus is an ex t remely rare tumor that can be very difficult to d iagnose unless the cl inician maintains a high degree of suspicion during the t ime of the diag- nostic evaluation. The purpose of this report is to pres-

Received from Wayne Memorial Hospital, Goldsboro, NC. * Attending Oral and Maxillofacial Surgeon, Department of Sur-

gery; in private practice, Goldsboro, NC. t Attending Anatomical and Clinical Pathologist, Department of

Surgery, Section of Pathology. Address correspondence and reprint requests to Dr Lutcavage:

2400 Wayne Memorial Dr, Goldsboro, NC 27534.

© 1995 American Association of Oral and Maxillofacial Surgeons

0278-2391/95/5304-002053,00/0

ent a pat ient who had a pr imary sphenoid sinus carci- noma.

Report of Case

A 38-year-old black man reported for follow-up 12 days after having undergone treatment for an apparent dental in- fection at Wayne Memorial Hospital (Goldsboro, NC). He had initially seen his family physician 2 months prior to this admission for mandibular pain, limitation of mandibular motion, and a prominent right neck swelling. He was placed on an oral antibiotic regimen and his symptoms had partially resolved. However, a recurrence necessitated a visit to the Emergency Department where an oral and maxillofacial sur- gery consultation was obtained. The patient was admitted, placed on parenteral antibiotic therapy, and had multiple abscessed root tips removed. He was subsequently dis-